Sulfonylureas: Diabetes Treatment

Sulfonylureas Overview

• This class of oral hypoglycemic agents treats Type 2 Diabetes Mellitus (T2DM).
• Effective treatment necessitates a functioning pancreas.
• The action involves stimulating insulin release from pancreatic beta-islet cells.
• A key adverse effect to monitor for is hypoglycemia, which can occur regardless of blood glucose levels.

Prototype and Classifications of Sulfonylureas

• Second-generation sulfonylurea Glipizide is the prototype medication
• Tolbutamide is another example of a first-generation sulfonylurea
• Second-generation sulfonylureas show greater potency and fewer drug interactions compared to their first-generation counterparts.

Mechanism of Action

• These drugs stimulate insulin secretion from pancreatic beta-islet cells.
• They do not work for Type 1 Diabetes Mellitus (T1DM), where insulin production is absent.
• By reducing blood glucose, they do increase the risk of hypoglycemia.

Sulfonylureas - Adverse Reactions

• Mild hypoglycemia is a common adverse reaction, especially with impaired kidney or liver function.
• Other adverse effects: nausea and diarrhea

Sulfonylureas - Nursing Interventions

• Watch for early symptoms of hypoglycemia, such as tremors, fatigue, diaphoresis, tachycardia, hunger, and dizziness.
• Conscious clients experiencing a hypoglycemic attack should consume 2-3 tsp of sugar, 4 oz of juice, honey, or glucose tablets.
• Unconscious clients require IV dextrose (D50W) or glucagon administered IM/SQ.
• Closely monitor blood glucose every 15-20 minutes until stabilization.
• Report persistent nausea, vomiting, or diarrhea to the healthcare provider.
• Monitor CBC to assess for decreased counts.

Sulfonylureas - Safety Considerations

• Brain function is especially susceptible to hypoglycemia's effects given its reliance on glucose for energy.
• Understanding and identifying early signs of hypoglycemia is vital to preventing confusion, behavioral changes, or more severe complications.
• Involve family and friends in education, so they can recognize hypoglycemia symptoms and respond appropriately.

Sulfonylureas - Administration Guidelines

• Oral glipizide should be taken about 30 minutes before meals.
• Immediate-release formulations: The medication is taken once daily, and doses exceeding 15 mg should be divided into two administrations.
• Sustained-release forms: These forms should never be crushed nor chewed.
• It's not advisable to take these at bedtime, as peak action occurs within 1-2 hours.

Sulfonylureas - Client Education

• It's recommended that patients with diabetes wear a medical alert bracelet to indicate their condition and medication use.
• Clients should always carry glucose tablets or a carbohydrate snack.
• Educate the necessity of regular blood glucose monitoring with a glucometer for accurate treatment.
• Any recurring occurrences of hypoglycemia should be brought to the attention of the healthcare provider.
• Managing nausea includes lying down and maintaining an adequate carbohydrate consumption.

Sulfonylureas - Contraindications and Precautions

• Pregnancy and lactation are contraindications.
• Sulfonylureas are not suitable those with established diabetic ketoacidosis (DKA).
• Exercise cautionary administration in patients with impaired hepatic and or renal function.
• Similarly, caution with adrenal or pituitary insufficiency.

Sulfonylureas - Interactions

• Alcohol may cause disulfiram-like reactions—nausea, vomiting, palpitations, flushing and may increase hypoglycemia.
• Medications including sulfonamide antibiotics, NSAIDs, oral anticoagulants, salicylates, MAOIs, and cimetidine increase the risk of hypoglycemia.
• Thiazide diuretics counteract the effects of Sulfonylureas.
• Beta Blockers may mask key signs of hypoglycemia like tachycardia.

Key Takeaways of Sulfonylureas

• These agents should be taken 30 minutes before meals, in the morning or divided throughout the day.
• Given the risk for hypoglycemia, clients should frequently monitor blood glucose.
• Avoiding alcohol can help prevent adverse reactions and hypoglycemia.
• Long-acting tablets should never be crushed nor chewed.
• Regularly monitor blood glucose and report frequent episodes of hypoglycemia.
• This oral antidiabetic medication acts by stimulating insulin production to thereby lower blood sugar.
• Sulfonylureas are for Type 2 diabetes, which means you must have some insulin production.

MCQ Answers

• Glipizide is the prototype medication for sulfonylureas.
• Sulfonylureas work by stimulating insulin release from the pancreas.
• A client with Type 1 Diabetes Mellitus is not a suitable candidate for sulfonylurea therapy.
• Hypoglycemia is a major adverse effect of sulfonylureas.
• A client taking glipizide should always carry a carbohydrate snack or glucose tablets.

SATA Answers

• Signs of Hypoglycemia: Shakiness, diaphoresis, tachycardia, confusion are all possible.
• Medications that may increase hypoglycemia risk: NSAIDs, Sulfonamide antibiotics, Beta Blockers, and MAOIs may all be implicated.

Quick Facts about Glipizide Administration

• Glipizide, a Sulfonylurea, should not be taken at bedtime.

True statements regarding Sulfonylureas:

• Alcohol use should be avoided, to prevent disulfiram-like reactions.
• Use of beta-blockers may mask tachycardia, a symptom of hypoglycemia.

What should be done when a client is experiencing hypoglycemia?

• If the client is conscious, administer 2-3 tsp of sugar or 4 oz of orange juice, honey, or glucose tablets.
• Sulfonylureas are not used in Type 1 diabetes mellitus as they require a functioning pancreas that produces its own insulin.
• Contraindications: pregnancy, lactation, and diabetic ketoacidosis (DKA).
• Instructions for sustained-release glipizide: take 30 minutes before the first meal of the day and do not crush or chew.
• Glipizide and Sulfonylureas may require periodic CBC (complete blood count) monitoring to detect blood dyscrasias such as leukopenia, thrombocytopenia or aplastic anemia.

Meglitinides Overview

• This class of medicine is an oral hypoglycemic, also known as Glinides
• Prototype medication is Repaglinide
• One other medicine is Nateglinide

Meglitinides Pharmacological Action

• Stimulates the beta-islet cells in the pancreas to release insulin
• A functioning pancreas must be in place
• If sulfonylureas do not work for a client, neither will meglitinides

Meglitinides Adverse Rxns

• Mild Hypoglycemia, especially with the client has liver impairment
• Possible nausea and vomiting

Meglitinides Interventions

• Monitor hypoglycemic signs and symptoms
• If conscious and alert, provide simple carbs
• If unconscious with IV access, provide D50W
• If unconscious without IV access, inject parenteral glucagon
• Check blood glucose frequently, 15-20 minutes until stable
• Monitor for persistent GI upset and notify provider
• CBC needs to be periodically checked

Meglitinides Admin

• Administer orally no more than 30 min before meal!
• Usually prescribed 3x daily
• If meal is skipped, skip a dose
• If eating more, add a dose
• Do not exceed 4 doses daily

Meglitinides Client Instructions

• Wear a medical alert bracelet
• Understand and recognize hypo- and hyperglycemia
• How to treat if symptoms develop
• Always carry a snack
• Nausea Management:
  • Lie down if feeling nauseated.
  • Ensure adequate carbohydrate intake to prevent hypoglycemia.

Meglitinides Contra

• Diabetic ketoacidosis
• Caution with Older adults.
• Caution with Renal and Liver dysfunction
• Caution with Systemic infection
• Caution with Endocrine disorders

Meglitinides Interactions

• Know that Erythromycin, Gemfibrozil, and Chloramphenicol can cause hypoglycemia
• Decreased Hypoglycemic Effects With: Alcohol, Corticosteroids, Rifampin
• Other:* NSAIDs, warfarin, loop diuretics, anabolic steroids can alter blood glucose levels. prototype = Repaglinide. Give meal 3x daily , 30 min b4 meal.

Key answers

• Repaglinide is the prototype medication for the meglitinide class.
• They function by stimulating insulin release from the pancreas.
• An impaired liver function client is most likely to experience mild hypoglycemia when using meglitinides.
• Repaglinide must be administered no more than 30 minutes before meals- if the meal is skipped, skip the dose!
• Hypoglycemia is a common side effect